ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Day 4 started with a session on PrEP in High Income Settings with a panel from USA and Europe and Jean -Michel Molina from France where PrEP has already been implemented.

It was interesting to listen to the discussion - everyone was in agreement of the value of PrEP and no-one had concerns about resistance or side-effects. There was debate about daily PrEP or on demand PrEP and how the choice will improve uptake and adherence.

There was concern about the cost of PrEP and who will access it and Keith Rawlings from Gilead in USA gave an excellent presentation on the demographics of the HIV positive population in the USA and the demographics of the PrEP accessing population - those that need it most do not access it.

There was also an interesting presentation about delivery modes - tablets, long acting injectables or slow release preparations - a Dapivirine vaginal ring.

Should treatment for Rectal Gonorrhoea and Chlamydia include PrEP??

The most surprising statement that was made today was in the last session of the day by Dong Wie from Nanjing China. In China, they only have access to six antiretroviral drugs. I found that difficult to believe but made me appreciate the range of drugs that we have in Australia.

The day started with the Lock lecture delivered by Julio Montaner from British Columbia. The overwhelming messages were:

Treatment as Prevention to prevent morbidity and mortality

ART is 100 % effective in preventing vertical transmission

While the end of the pandemic may be in sight, we need to be vigilant as there are problematic clusters of HIV emerging all the time and there is potential for the fire to be rekindled.

Jens Lundgren from Copenhagen provided a convincing argument for early vs deferred treatment but warned that CVS risk protection was not convincing with early treatment.

Cheryl Johnson from WHO Geneva provided a very insightful talk on the barriers to HIV testing and it is very apparent that this is the area that we need to improve upon if we are to meet the 90 90 90 target. The identification of the positive patients is the most important part of the cascade and we are still failing to identify them.

There was some controversy over HIV self testing and "At Home" STI screening but it was a suggestion to be able to test more people and reducing the stigma of having to go to a test centre and have the test. Also need to look at the accessibility of testing to patients - hours of opening and outreach centres.

Also discussed was differential ART delivery and the number of times per year that a stable patient needed to see a doctor.

There were a few Interactive cases which were very practical and could have been adapted to suit the practice of most of the clinicians in the audience.

We have just heard from 7 speakers on the status of PrEP across Euro and North America. There is considerable support for PrEP and incredible consistency across the regions in both trends and challenges a s well as interest.

Clearly there is no debate about the efficacy of PrEP, thought there remain differences in choice about daily or on demand PrEP. There seems to be considerable comfort in the level of resistance, side-effects and toxicities, while these may be appearing they are at such low levels as to no impact support for PrEP.

There is also a very generalised concern about cost of PrEP, but a growing confidence that cost issues will be addressed. How to implement PrEP is where the differences are most striking. Many people are indicating that PrEP must be resourced by cutting back in other areas. Cost effectiveness remains linked to the cost of the drug ad the level of risk, but a number of speakers also introduced location or background prevalence into that assessment.

PrEP access, at least in a number of settings, does not match HIV transmission risk. One presenter gave a detailed account of where PrEP is accessed and by whom. Overwhelmingly PrEP access in the USA favours white MSM, yet black and hispanic MSM and women are at much greater risk. This is s strong take home message. We will need to make sure that PrEP can be assessed by at risk populations and communities at greater vulnerability.

-enc partner to start ARV (This is more effective than PrEP) and cont using condoms, consider PrEP for her-PrEP-TDF alone risk reduction in women 71% in discordant couples when pos partner NOT on ARVs; if drug found in plasma, then inc efficacy to 80%; TasP more effective wth 96% reduction in linked transmissions.

HIV incidence was 0.2 per 100 yrs per person yrs when TasP and PrEP used together

Consider using condoms too;

-If they want a baby - and partner started on ARV but not yet fully suppressed-

could start PrEP-let them know that not yet fully studied in pregnancy, in real life, they present already pregnant' -does she need it? If partners VL is down to 60 copies/ml- depends on the risk they are prepared to take.

May take a bit longer til his VL undetectable and use PrEP

If parter has UDVL for 6 months, may not need PrEP to prevent infection, but if pt needs reassurance then can use PrEP

HPTN 052 now has 5 yr follow up -93% reduction in incidence of linked transmissions.

8 linked cases of linked infections- most early on day 35-84 after starting ART, no linked infection when HIV stably suppressed to <400copies/ml

Day 2 of the HIV Drug Therapy Congress in Glasgow began with an excellent presentation by Dr Julio Montanerfrom the British Columbia Centre for Excellence in HIV/AIDS on “HIV treatment as prevention: from a research hypothesis to a new global target and beyond.”He argued that the “treatment as prevention” approach reduces morbidity, mortality and HIV transmission, and is also the most cost-effective approach to managing the HIV epidemic.Is the current UNAIDS target of 90:90:90 by 2020 feasible?This would equate to 91% of people with HIV diagnosed as HIV positive, 81% of all people with HIV being on ART, with 73% of all people with HIV being successfully virally suppressed.The current global figures fall far short of this, being 57%, 46% and 38% respectively.

Dr Montaner emphasised the importance of being alert to picking up clusters of increased incidence in specific populations quickly, with efforts to identify networks, increase contact tracing and testing, and make use of PrEP and rapid institution of treatment.He also talked about the importance of political support and mentioned previous tendencies of government in various regions to lose enthusiasm for addressing the HIV epidemic when rates appeared to be waning.He said that the piecemeal approach won’t work, and control of the HIV epidemic globally is clearly the work of a generation, not a few years.

Dr Jens Lundgren of the Rigshospitalet in Copenhagen reviewed the insights gained from the START study and the substudies related to it.This study was especially important in that it is globally applicable, being conducted over 4 years in 35 countries (250 sites), with a sample size of 4600 people, randomised to either early ART or deferred ART (until CD4 count less than 350cells/mm3).It has changed the management of HIV globally, with all subsequent guidelines advising immediate rather than delayed treatment.

Some of the unexpected results of the START trial were that in the deferred arm there were both increased rates of opportunistic infections (although CD4 counts were often in the order of 500-600) as well as increased rates of various malignancies.It had been hypothesised that the immediate treatment arm may see a reduction in CVD risk due to reduction in inflammation, but this was not the case – in fact there was no change in CVD risk.A substudy published earlier this week in the Lancet Respiratory Medicine journal showed that, if anything, the deferred arm had reduced rates of COPD.Another substudy on bone mineral density has clearly shown that early treatment leads to more accelerated decline in BMD.

Later in the day, Dr Jean-Michel Molina from Saint-Louis Hospital and the University of Paris presented a case study of the use of PrEP in a thirty year old female patient with a HIV-positive male partner.The various options for reducing transmission of HIV to the female partner (who wished to become pregnant) were discussed; the most important point being of course effective viral suppression of the male partner’s HIV, as well as condom use and also the possible addition of PrEP for the female partner as an additional precaution when she wishes to conceive.The previously-favoured approach of IVF with sperm-washing was no longer seen as the most appropriate treatment, as rates of pregnancy are much lower with this approach than with natural conception and the panel commented that an undetectable viral load was reliably associated with lack of transmission of HIV to the negative partner in studies of serodiscordant couples as well as their clinical experience of similar cases.